James A. Sliwa

Function-limiting dysesthetic pain syndrome among traumatic spinal cord injury patients: a cross-sectional study

&NA; Diffuse burning dysesthetic sensations distal to the level of spinal injury are the most common and disabling painful sequelae of traumatic spinal cord injury (SCI). In a cross‐sectional study of 19 SCI patients, clinical characteristics and results of 3 validated pain measurement instruments (McGill Pain Questionnaire, Stembach Pain Intensity and Zung Pain and Distress Scale) were used to develop a profile of function‐limiting dysesthetic pain sydrome (DPS). Compared to a cohort of 147 patients admitted to the Midwest Regional Spinal Cord Injury Care System during the time period of the study, subjects were more likely to have paraplegia, incomplete sensory myelopathy, gunshot wounds to the spine and non‐surgical spinal stabilization. Most patients described the pain as ‘cutting,’ &bgr;urning,’ ‘piercing,’ ‘radiating’ and ‘tight.’ The majority of patients located the pain internally and in the lower extremities. Values obtained from 6 McGill Pain Questionnaire subscales, 2 Sternbach Pain Intensity ratings and the Zung Pain and Distress index equalled or exceeded those reported for other pain syndromes. Use of these validated pain measures resulted in a systematic comprehensive assessment of function‐limiting DPS following SCI.

Functional outcome following rehabilitation of the cancer patient

OBJECTIVE To identify impairments resulting from cancer or its treatment in patients undergoing inpatient rehabilitation, to assess the extent of functional gains, and to determine if cancer type, ongoing radiation treatment, or the presence of metastatic disease influences functional improvement. DESIGN AND SETTING A retrospective, case series of cancer patients undergoing inpatient rehabilitation at a free-standing, university-affiliated rehabilitation hospital. PARTICIPANTS A referred sample of 159 patients admitted because of functional impairments resulting from cancer or its treatment during a 2-year time period. INTERVENTION Comprehensive inpatient rehabilitation. MAIN OUTCOME MEASURE Functional status as measured by the motor score of the Functional Independence Measure. RESULTS Significant functional gains were made between admission (mean = 42.9) and discharge (mean = 56.0; p < .001), with all cancer subgroups making similar gains. The presence of metastatic disease did not influence functional outcome, and those patients receiving radiation actually made larger functional improvements (p = .025). CONCLUSION Individuals impaired by cancer or its treatment benefit from inpatient rehabilitation. The presence of metastatic disease or ongoing radiation should not preclude participation.

Trazodone hydrochloride in the treatment of dysesthetic pain in traumatic myelopathy: a randomized, double-blind, placebo-controlled study

&NA; Dysesthetic pain following traumatic myelopathy is characterized by diffuse burning and tingling sensations distal to the level of spinal injury. The dysesthetic pain syndrome (DPS) can compromise performance of functional abilities and inhibit participation in rehabilitation programs. Recent laboratory evidence suggests that antidepressant medications with selective inhibition of serotonin reuptake in the brain may be associated with superior analgesic effect compared to such non‐selective agents as amitriptyline. Trazodone hydrochloride is a potent presynaptic serotonin reuptake blocker with few anticholinergic and cardiovascular side effects. This study was a randomized, double‐blind, placebocontrolled trial of trazodone hydrochloride for the treatment of DPS. Following a 2‐week placebo lead‐in period, patients were randomized to a 6‐week course of 150 mg trazodone hydrochloride/day or placebo. Evaluations of pain quality and intensity were performed at 2‐week intervals, utilizing the McGill Pain Questionnaire, Sternbach Pain Intensity Scale, and Zung Pain and Distress Index. Neurologic examination and assessment of side effects were performed at each evaluation session. No significant changes were noted in reported pain measures between patients allocated to the active drug group and those given placebo during the course of the protocol. However, significantly more patients randomized to trazodone complained of side effects and prematurely terminated their participation in the study. The results of this investigation are consistent with those of other earlier trials which indicate that such antidepressant medications as trazodone hydrochloride which selectively inhibit presynaptic reuptake of serotonin, may not be effective in the control of certain pain syndromes. These results do not preclude the possible utility of these agents in the treatment of other pain syndromes or at higher doses than previously studied.

Ischemic myelopathy: A review of spinal vasculature and related clinical syndromes

This article provides a comprehensive review of spinal vascular anatomy (arterial and venous) and clinical syndromes that result from the disruption of blood flow to or from the spinal cord. Blood is supplied to the spinal cord through three longitudinal channels: one anterior and two posterior spinal arteries. These vessels, which originate as branches of the vertebral arteries and run caudally along the spinal cord, are augmented by a variable number of medullary arteries. A vascular ring, or vasa coronae, surrounds the cord and connects these longitudinal channels. Central arteries from the anterior spinal artery and penetrating vessels from the vasa coronae provide blood directly to the cord. Venous flow from the spinal cord is also accomplished through a system of anterior and posterior spinal vessels draining through a variable number of medullary veins and an extensive valveless vertebral venous plexus. The disruption of blood flow to or from the spinal cord can result in infarction, with permanent neurologic loss and physical impairment. The clinical presentation in cases of ischemic myelopathy can be variable. Discrete syndromes based on the occlusion of specific vessels are reported and include venous infarction, anterior and posterior spinal artery syndrome, and central infarction.

System identification of tendon reflex dynamics

Patellar tendon reflexes were evaluated in 12 healthy adult subjects using several measures of the reflex responses and of the system input-output relationship. A hand-held instrumented hammer was used to tap the patellar tendon and to elicit the reflex response. Tendon reflex dynamics were estimated using the recorded tapping force (as input) and the quadriceps muscle electromyogram and knee joint extension torque signals (as output). A dome-shaped rubber pad was mounted onto the most sensitive spot on the patellar tendon, where it served as a tapping target, and helped to reduce the reflex variability significantly (p < 0.01). The input-output properties of the system relating the reflex torque to the tapping force were characterized using several measures: the tendon reflex gain (Gtr), contraction rate (Rc), and half-relaxation rate (Rhr). Reflex loop delay (t(d)) was estimated using the delay from the onset of tapping force to the onset of reflex torque. We determined that these system parameters provided significantly more repeatable and consistent characterization of tendon reflexes than did reflexive torque or EMG signals alone (p < 0.025). The input-output relationship relating the EMG signals of the stretched muscle to the tapping force was also identified to help characterize neuromuscular dynamics of tendon reflexes. The observed sensitivity and consistency of the reflex system measures suggest that with appropriate simplification of the instrumentation, these methods may prove useful in routine clinical practice, and may allow more precise quantification of the tendon jerk than is currently feasible with standard clinical tests.

Upper urinary tract abnormalities in multiple sclerosis patients with urinary symptoms.

OBJECTIVE To determine the prevalence of upper urinary tract complications in multiple sclerosis (MS) patients with urinary symptoms, and to determine if an association exists between degree of physical impairment and upper urinary tract complications. DESIGN AND SETTING A cohort study of MS patients seeking treatment at a freestanding, university-affiliated rehabilitation hospital. PARTICIPANTS A referred sample of 48 patients with MS, exacerbation-free for 6 months with symptoms of neurogenic bladder dysfunction. For each patient, demographic data, disease characteristics, and urologic history was obtained. Using the Kurtzke Expanded Disability Status Scale (EDSS), participants were divided into a control (EDSS < 7) and study (EDSS >/= 7) group. INTERVENTION Ultrasound examination of the upper urinary tract. MAIN OUTCOME MEASURE Significant MS-related abnormalities of the upper respiratory tract. RESULTS Ten of 48 patients (21%) had significant MS-related upper urinary tract abnormalities, which were evenly distributed between control and study groups. In the more disabled study group, abnormalities were associated with the symptom of urinary hesitancy (p < .05) and form of bladder management (p < .05). CONCLUSIONS Routine screening for upper urinary tract complications appears indicated in a select group of MS patients with urinary symptoms.

Inpatient Rehabilitation of Patients with Cancer: Efficacy and Treatment Considerations

Although cancer can affect a great number of individuals and is the second leading cause of death in the United States, the number of individuals admitted to acute inpatient rehabilitation units with impairments primarily as the result of cancer diagnoses remains small. There is a lack of awareness among health care providers as to the functional loss that can be associated with cancer and the potential benefits of inpatient rehabilitation. Furthermore, financial pressures from third‐party payors may dissuade the admission of patients with cancer for inpatient rehabilitation. This is a narrative review of the literature with respect to the efficacy and potential benefits of inpatient rehabilitation for patients with cancer. The findings of studies on the rehabilitation of general cancer populations are presented, with a focus on functional outcomes, medical complications and transfer rates, and common symptoms encountered during inpatient rehabilitation. Studies that focus on tumors involving the brain and spinal cord are separately analyzed. Functional outcomes by tumor location are reviewed with respect to tumor type, recurrence, and comparison with nontumor diagnoses. In addition, the effects of concomitant treatments on functional outcomes and possible correlations of survival with functional outcome are presented. Justification for admission of patients with cancer diagnoses to inpatient rehabilitation units, as well as implications for management of these patients during their rehabilitation stay, will be summarized.

Rehabilitation-specific communication skills training: improving the physician-patient relationship.

Sliwa JA, Makoul G, Betts H: Rehabilitation-specific communication skills training: Improving the physician-patient relationship. Am J Phys Med Rehabil 2002;81:126–132. ObjectiveEvaluate the effectiveness of a rehabilitation-specific communication skills training program for physicians. DesignThree groups of rehabilitation patients were interviewed 3 mo after discharge, one group before and two groups after implementation of a communication skills training program. The setting was a free-standing rehabilitation hospital with a residency training program. A total of 245 patients who had been discharged from the rehabilitation hospital participated in the study. A communication skills training program that was designed specifically for physicians and patients in the rehabilitation setting was used as an intervention. Patients’ perceptions of the extent to which physicians accomplished 18 communication tasks highlighted by the training program were gauged in a structured telephone interview. ResultsParticipants interviewed after the training program was implemented more strongly agreed that their physicians accomplished the communication tasks assessed than did patients interviewed before the training program began. On 14 of 18 items, the differences were statistically significant (P < 0.05). ConclusionSpecialty-specific communication training can improve physician communication skills.

Paraneoplastic subacute cerebellar degeneration : Functional improvement and the role of rehabilitation.

Paraneoplastic syndromes, or the remote effects of cancer on the nervous system, can result in significant functional impairment. One syndrome in particular, paraneoplastic subacute cerebellar degeneration (PSCD), may be severely disabling. Patients with PSCD can experience severe ataxia resulting in an inability to ambulate or perform their activities of daily living. Little has been written about the value of rehabilitation in cases of paraneoplastic syndrome. We report the case of a 51-year-old woman with PSCD who experienced improvements in all functional activities after comprehensive inpatient rehabilitation. She has maintained her improved functional status after discharge; her case is testimony to the value of rehabilitation in paraneoplastic syndrome.

Physical rehabilitation of the cancer patient.

Significant numbers of cancer patients have physical limitations as a result of their cancer or its treatment. Most commonly, this impairment results from prolonged bed rest and deconditioning syndrome or neurologic loss frequently coupled with deconditioning. What few studies have been done show that functional improvement through rehabilitation does occur. For many cancer patients, rehabilitation is an appropriate option, viewed favorably by patients and their families. However, as opposed to other causes of impairment, the benefits and goals of rehabilitation must be carefully weighed in concert with the goals of the cancer patient, all in an effort to add to his or her quality of life.